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21255 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Building Address: - /'� A C /quo / 6/7"gy. oda G GJ -.R.— one: A Rondo 7"QndA'd- 2x9--363 CITY OF CUPERTINOBUILDINGDIVISION lc� Coame<ors Name: L'c. APPLICATION I PERMIT )f�'f'9y/oO1L�g7C spPcia41,C7J h7c,veq�B4 BUILDINGELECTRICALPLUMBING-MEGHAMCAL CATEGORY CONTROL# Architect/Eagineee Llc.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Adtlres: - PERMITISS(IANCE LICENSED CONTR under rDECLARATION I hereby aon7Othat lam0cen3oftheerprovland Pro Cssims9(commanc- AIPPLIANCESRES[DENTIALlngwitJOB DESCRIPTION hem.h.full force fDlvfect. (the Bupneseand Pro(esponaCnde,and my lianas lalns force and c,# PANELS Licence Class _ Lic.p_. Date ContraRor SPS /. UP TO 200 AMPS ARCHITECTS DECLARATION 201-1000 AMPS Pqqp±±IXO O I understand my plana shall be used as public records. OVER 1000 AMPS - SQ.FT.FLOOR AREA $/SQ.FT. E o�j Licensed Professional SICNSELECTRICAL fn 6 OWNER-BUILDER DECLARATION SPECIAL CI(CUIT/MI zp„ I herebyafRrmthatl am exempt from the Contractors Licence Lzwforthe oo following reason.(Section 7011.5,Business and Profesbna Code:Any city ar O'Z TEMP.METER OR LE IN F� rountywhich requlr.aperMttocorotruct,ilter,impmve,tlemoliah,orrepair any structure prior to Its Issuance,also requires,the applicant for such permit to POWER DEVECES file a signed statement that he Is licensed pursuant to the provisions of the Ow ContractorsLlceseLaw(Chapter9(commenting�0 sion3oftheBusnsrandProfesslo.Code)arthathweithm7000)of Diedisexapvl- SWMMNC POOL EL VALUATION . the basis for the alleged exemption. Any violation of Section 7MI.5 by any OUTLE SWITCHESES t t Oco c eMAc applicant for a permit subjects the applicant to a civil penalty of act more than "l five 1,as nerodollaf thepr. NEW FNMA TR SQ. STORIES TYPECONSTRUCTION �n ❑I,as owner of the property,or my employes with wages r their dole sale(S compensation,will Business and k,and Pnefesthes Code:The not Intended o License ed for Law O sale(Sec.apply to ainow end f property Code:The uilds or impctola Limos law (?j3� dos nonsuch torn owner ofplf ropertywho nemporlmprovestherevided atsuch OCC.GROUP RES.ENDS or,and C: whodoes amworkMmsededorough hisownemp,hcxveamtheuilding or improvements.red Intendedproffered pleflo,ILhowevep deer ill haw TOTAL: ' Improvement baoldwlthln oreyearofcomplelioo,rhe owner-bu0derwlll have ' t"rden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN L j L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to corstmct the project(Sec.7044,Business and Professlore,Code: 1 The Contractor's Licence law dos act apply to an owner of property who AL77R-DRAIN&VENT- Wilds or Improves thereon,and who contracts for such ptdjetts with a WATER(EM �R.tfaetor(s)Bansed pursuant to the Contractor'.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY L�I am exempt under Sec. B&P C for this reason �B TTai no nm OwnerDate DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_ RECEIPT p WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N E31 he affirm that t have a certificate of concent to ora RECEIPT# artllcate of Workers'Comps.atlonl.uranre aacertifkd ropythepythereofof(Sec. CAS F.A.SYSTEM-1 INCA OUTLETS PARKFEE Y N 3800,Lab C.) y Polity# DING DIM Com an GAS EA.SYSTEM-OVER � Y - Y- //Y/ BUILDING DIVISIONFEES CertBled copy I here by furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ❑CertIted spy b filed with the tlty Inspection divipon. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATdiftINSURANCE - SEWER-SANITARYDate Remi t# (This section need ns, COMPENSATION Ifthepermit bfaone hundred dollars ($100)orless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N I amlythat In the performance of thework forwhlch this permit is Ismnd, — I shall not employ an/person In any manner so as to become subject to the WATER SYSIF.M/TREATING Workers'Compensation laws of California.Date PAID' Z Z Applicant O NEW RESIDENTIAL PLMB. SQFT. Date Remi t# Z NOTICETO APPLICANT:If,after making thin Certificate of Exemption,you Fshould become sub)ect to the Workers'Compeaation provisions ofthe Labor TOTAL: W Code,you mu at forthwith comply with such provisions orthis permit shill be BUILDING FEE L LU j deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE d G I hereby affirm that thereis a construction lending agencyfor the perform ELECTRIC FEE U Lender N L) Z work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ( 4 Lenders Name PLUMBING FEE IL I- Lenders Adde, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OW Iemilyth.0 havereadthlaappli.tlonand atatethattheabove Nfmmation 1 Is correct.l agree to comply with all city and county ordinances and pate laws PERMIT ISSUANCE FEES PAID: >. N relating tobuilding construction,and hereby authorise representatives presentives ofthis (— Z sty to enter upon the above-mentioned property for Impaction purposes. ALTER OR ADDTO MECH. (We)agree to save,Indemnity an d keep harmless the City of Cupertino Date Receipt# V against liabilities,judgments,caps and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL: ..Smsaid City In consequence of the gram ing a this permit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Ga-,L �i�o a— — eoo—y-9y S tore of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) maDate Recei [# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Cade cBon 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL' [-IYea 161 No Will the applicant or fumm building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit hazardous air conlamlanta as defined by the Bay Area Air , Quality Management District? BOILER-COMP(3HP OR 100,000 BTU) Yea ©No have read the hazalloua materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 STU) the California Health&SafetyCode,Sectio.Z5505,25533 and 25534. I understand that lithe building does not mrrently have a tenant.that It 6 m NEW RESIDENTIAL MECH. SQ.FT. responsibility to notify the occupant of the requirements which at be met priort race of a Certificate of 0mpancy. Own�r.Lr authorised agent Data ^R �" V TOTAL: I55 OFFICE COPY . \